Simplified Meal Announcement Versus Precise Carbohydrate Counting in Adolescents With Type 1 Diabetes Using the MiniMed 780G Advanced Hybrid Closed Loop System: A Randomized Controlled Trial Comparing Glucose Control

Efficacy and Safety of a Non-Carbohydrate Counting Meal Bolus Strategy in Adults with Type 1 Diabetes Using Open-Source Automated Insulin Delivery

Aims: This study addressed the challenge of postprandial glycemic variability in type 1 diabetes (T1D), even with AID (automated insulin delivery). We evaluated the effectiveness of a non-carbohydrate counting (non-CC) meal bolus strategy in adults with T1D utilizing open-source AID. Methods: A total of 32 adults with T1D, aged 18 to 50 years, participated in a randomized crossover trial utilizing open-source AID. Following a 7-day run-in period, participants were randomly assigned to one of two groups: automatic mode (closed loop) or manual mode (open loop). After 2 weeks, the participants underwent a crossover to the alternate treatment mode. Prandial boluses were administered according to a sliding scale based on preprandial glucose levels, without utilizing either the exact carbohydrate content of meals or meal announcement buttons. The study compared the differences in time in range (TIR) and insulin dosage across the different phases. Results: Compared with the open-loop phase, the TIR for patients during the closed-loop phase increased significantly during the night (75.45% ± 12.08% vs. 83.05% ± 7.20%, P < 0.001) and 24 h (73.40% ± 9.98% vs. 79.21% ± 4.84%, P = 0.019), with a more pronounced effect observed at night. During the closed-loop phase, the frequency of 24-h hypoglycemic events (＜3.9 mmol/L) was reduced compared with the open-loop phase, with no difference in nocturnal hypoglycemic events. In addition, compared with the open-loop phase, there were no significant differences in average postprandial blood glucose and peak blood glucose levels during the closed-loop phase; however, the time to reach peak postprandial blood glucose was delayed (86.06 ± 20.80 min vs. 99.08 ± 15.05 min, P < 0.001). Conclusions: A non-CC meal bolus strategy based on preprandial glucose in adults with T1D utilizing open-source AID effectively prevents glycemic excursions and maintains a mean TIR over 70%.

Tips for successful use of commercial automated insulin delivery systems: An expert paper of the Italian working group on diabetes and technology

In recent years, automated insulin delivery (AID) systems have transformed diabetes care with demonstrated benefits in glucose control, hypoglycemia risk, and psychosocial outcomes. Given that different systems show peculiarities in terms of components, approved indications of use, type of algorithm, modifiable settings, and additional features, with this expert paper, we aim to provide healthcare professionals with device-specific recommendations for the optimization of insulin therapy and diabetes self-management with the five commercial AID systems most commonly used in Italy. In detail, we provide educational tips and suggestions for adjustment of insulin dosing parameters to address specific glucose patterns as depicted by continuous glucose monitoring data and effectively manage physical activity or exercise.

Practical implementation of automated insulin delivery systems in 2025: A French position statement update

The advent of automated insulin delivery (AID) systems in 2020 marked a disruptive event in managing type 1 diabetes, benefiting children and adults alike. By 2024, advances in real-world data and research motivated an update to the French consensus on AID systems to expand accessibility, refine guidelines, and optimize patient follow-up. AID systems have consistently improved glycemic control by reducing HbA1c, increasing time-in-range (TIR), and minimizing hypoglycemia, with significant benefits even for specific populations such as individuals with poor glycemic control, brittle diabetes, children, very young children, pregnant women, those with insulin resistance or gastroparesis, or after bariatric surgery. Recent studies support the broadening of AID indications for these special situations, also demonstrating safe transitions directly from multiple daily injections. A careful selection of the most appropriate system for these special situations is essential to achieve optimal personalization for each patient. Training healthcare professionals and patients remains essential for optimizing AID usage. Updated guidelines emphasize multidisciplinary education, telemonitoring, and individualized follow-up to ensure safety and efficacy. The potential of fully automated systems and adjunctive therapies, such as GLP-1 receptor agonists, is being explored alongside promising evidence that AID systems improve glycemic control in type 2 diabetes without increasing hypoglycemia. The future of AID systems lies in innovation and expanding their applicability across diverse patient populations.

Expert panel opinion on the optimal educational pathway for diabetes educators for training people with type 1 diabetes on the MiniMed™ 780G system: a Delphi consensus

INTRODUCTION

The MiniMed™ 780G system is an advanced insulin pump system incorporating an AHCL (Advanced Hybrid Close Loop) algorithm that automatically adjusts insulin delivery based on glucose levels. All guidelines recommend the use of Automated Insulin Delivery therapy for people with type 1 diabetes (PWT1D) and they highlight that a specifically trained and expert team should provide training on HCL systems for PWT1D, but none of the publications detail the curriculum profile that diabetes educators should have. This paper aims to establish a consensus on the optimal educational pathway for diabetes educators on the MiniMed™ 780G system.

METHODS

An Expert Panel (EP) of 11 key opinion educators in diabetes technology in the EMEA area was assembled. Using the Delphi method, a consensus questionnaire based on the literature research was created, discussed and validated by the EP members. An agreement level of ≥ 75% was considered a strong consensus.

RESULTS

EP members had on average 16.3 years of clinical experience and followed at least 50 PWT1D using the MiniMed™ 780G system. All EP members agreed that a structured educational pathway to train diabetes educators in the use of the MiniMed™ 780G system is needed. 100% of the EP members agreed that the pathway should include a mentorship programme and in-field training; 90% agreed on using face-to-face training with the support of e-learning modules. The EP members believed that minimum competency standards for diabetes educators around the principles of diabetes care and education are needed.

CONCLUSION

The educational pathway created by the EP showed that skills are needed at an advanced level and that mentorship in developing these skills is critical. This pathway is vital for supporting the implementation of diabetes technology into everyday life and can remove barriers and increase access to PWT1D.

Evaluation of an Automated Insulin Delivery System in the Management of Postprandial Glucose Levels During a Pediatric School Camp: The Control-IQ Potato Challenge

Background: Potatoes are a staple food, especially in pediatric populations, but they pose distinct challenges for individuals with type 1 diabetes (T1D). This study evaluated glycemic responses in youth with T1D using a second-generation automated insulin delivery system after consuming potatoes prepared by two methods: fried and boiled. Methods: The study was conducted during a 5-day school camp for unaccompanied youth with T1D, aged 11-17 years, who had been using the Tandem t:slim X2™ Control-IQ insulin pump for at least 6 months. On two separate days, participants consumed a standardized meal containing 240 g of either fried or boiled potatoes, considered as 38 g of carbohydrates. Continuous glucose monitoring (CGM) data were collected and analyzed for all participants. Results: Our study population consisted of 31 children and adolescents (mean age 14.2 ± 1.7 years). Time in range was slightly higher after consuming boiled potatoes compared with fried potatoes, though the difference was not statistically significant (73.7% vs. 67.8%; P = 0.225). Mean glucose changes from pre-meal to 3-h post-meal were comparable between groups (-34.3 vs. -25.4 mg/dL; P = 0.517). Similarly, no significant differences were observed in the area under the curve of glucose levels. However, the percentage of bolus insulin within the 3-h post-meal period tended to be higher after fried potato consumption (20.7% vs. 11.9%; P = 0.075). Conclusions: Despite differences in glycemic index and fat content, the Tandem t:slim X2 Control-IQ system effectively maintained satisfactory glucose control within the 3-h post-meal period for both fried and boiled potatoes.

Impact of Simplera Sync™ sensors and Extended™ Wear Infusion Sets on glycaemia and system performance of the MiniMed™ 780G system in children and young adults with previously high HbA1c

AIMS

The MiniMed™ 780G improves glycaemia and reduces burden in type 1 diabetes. We investigated how new all-in-one "Simplera Sync™" sensors and 7-day Extended™ Wear Infusion Sets (EIS) affect glycaemia and system performance in young people with previously elevated HbA1c levels (≥69 mmol/mol [≥8%]) after transitioning from 780G with Guardian 4™ sensors and 3-day infusion sets.

METHODS

We conducted an extension phase analysis in 75 participants (aged 7-25 years) initially enrolled in the CO-PILOT randomised controlled trial. For this analysis, baseline was defined as the period following the use of 780G with Guardian 4™ sensors and 3-day infusion sets. Participants then transitioned to 780G with Simplera Sync™ and EIS. We compared glycaemic and system performance outcomes from baseline to those after the transition to 780G with Simplera Sync™ and EIS.

RESULTS

Baseline HbA1c was 66.1 mmol/mol ± 14.2 mmol/mol and remained stable at 66.7 mmol/mol ± 11.2 mmol/mol after the transition (p = 0.38). Time in range (3.9-10.0 mmol/L [70-180 mg/dL]) at baseline was 58.5% ± 14.9% and 60.4% ± 15.7% after transition (p = 0.09). Time in tight range (3.9-7.8 mmol/L [70-140 mg/dL]) increased from 38.1% ± 13.1% at baseline to 40.5% ± 13.6% after the transition (p = 0.04). While using 780G with Simplera Sync™ and EIS, automation time increased from baseline 79.2% ± 25.9% to 85.8% ± 21.8% (p = 0.007), and sensor wear time from 80.7% ± 22.4% at baseline to 88.4% ± 17.2% (p < 0001).

CONCLUSIONS

Simplera Sync™ and EIS improved time in automation and sensor wear time when using 780G AHCL in this high-risk young population. This was associated with incremental improvement in time in tight range despite the challenges of this population.

Glucose metrics and device satisfaction in adults with type 1 diabetes using different treatment modalities: a multicenter, real-world observational study

AIMS

To evaluate glucose metrics, device satisfaction and diabetes impact in adults with type 1 diabetes using different treatment modalities in a real-life setting in Italy.

METHODS

This was a multicentre, nationwide, cross-sectional study. Candidates were consecutively evaluated for eligibility during their routine medical visit at the diabetes centre. Researchers collected comprehensive demographic, socioeconomic, anamnestic and clinical data, and administered the Diabetes Impact and Device Satisfaction scale.

RESULTS

From 2021 to 2022, a total of 428 subjects, 45% males, with a median age of 32 years (IQR 23-47) were recruited in 11 participating centres from all over Italy. No differences in age, physical activity, and diabetes impact were found for the different treatment modalities. HCL/AHCL and SAP groups reported higher device satisfaction vs. MDI + SMBG and MDI + CGM (p < 0.001). Subjects treated with HCL/AHCL exhibited significantly higher TIR and significantly lower time spent in hypoglycemia level 1, time spent in hyperglycemia, CV and GMI compared to MDI + CGM, and significantly higher TIR and significantly lower time spent in hypoglycemia level 2, time spent in hyperglycemia, and CV compared to SAP. Significant reduction in hypoglycemia level 2 was also found with PLGM compared to SAP. High education attainment was associated with optimal metabolic control.

CONCLUSION

Real-life use of advanced technologies for type 1 diabetes is associated with improved glucose metrics and device satisfaction. Education level also contributes to success of treatment.

Predictors of glycaemic improvement in children and young adults with type 1 diabetes and very elevated HbA1c using the MiniMed 780G system

AIMS

This study aimed to identify key factors with the greatest influence on glycaemic outcomes in young individuals with type 1 diabetes (T1D) and very elevated glycaemia after 3 months of automated insulin delivery (AID).

MATERIALS AND METHODS

Data were combined and analysed from two separate and previously published studies with similar inclusion criteria assessing AID (MiniMed 780G) efficacy among young individuals naïve to AID (aged 7-25 years) with glycated haemoglobin A1c (HbA1c) ≥69 mmol/mol (≥8.5%). Univariate and multivariate linear models were performed to explore factors leading to the greatest improvements in HbA1c and time in range 3.9-10.0 mmol/L (70-180 mg/dL; TIR).

RESULTS

A total of 99 young individuals (aged 17.3 ± 4.2 years; baseline HbA1c 92 ± 21 mmol/mol [10.6% ± 1.9%]) were included. After 3 months of AID use, HbA1c improved to 65 ± 16 mmol/mol (8.1% ± 1.5%) (-27 ± 23 mmol/mol; -2.5% ± 2.1% change), and TIR improved from 24.2% ± 13.5% to 58.4% ± 15.4% (p both <0.001). In the multivariate analysis, two key factors for both HbA1c and TIR improvement were identified: high baseline HbA1c (>100 mmol/mol [>11.0%]) and high time in automation mode (>80%), which led to decreased HbA1c by 27.0 mmol/mol (2.4%) and 14.2 mmol/mol (1.3%) and increased TIR by 6.1% and 11.1% (p all <0.05) respectively. Meal announcement frequency >3 times/day and glucose target of 5.5 mmol/L (100 mg/dL) also led to significant increases in TIR. No other factors, including age, prior use of multiple daily injection, ethnicity, gender and optimal active insulin time 2 h, contributed to statistically significant HbA1c or TIR improvement.

CONCLUSIONS

In young individuals naive to AID, those with the highest baseline HbA1c and high percentage time in automation experience the greatest benefits after initiation of AID. Sociodemographic background and carbohydrate counting adherence/knowledge should not prevent or delay access to AID technology (ACTRN12621000556842 and ACTRN12622001454763).

Parental perspectives following the implementation of advanced hybrid closed-loop therapy in children and adolescents with type 1 diabetes and elevated glycaemia

AIMS

To identify from a parental perspective facilitators and barriers of effective implementation of advanced hybrid closed-loop (AHCL) therapy in children and adolescents with type 1 diabetes (T1D) with elevated glycaemia.

METHODS

Semi-structured interviews were conducted with parents of participants while in a post-trial extension phase of the CO-PILOT randomized controlled trial. The Capability, Opportunity, Motivation, Behaviour Model and Theoretical Domain Framework informed the interviews and framework analysis.

RESULTS

Eleven parents of 9 children and adolescents were interviewed. The median age of their children and adolescents was 14.2 years (IQR 13.3-14.7) with median HbA1c 78 mmol/mol (IQR 75-86) (9.3% IQR 9-10) before starting AHCL. Facilitators of implementing AHCL therapy included the following: (1) knowledge acquired from training, (2) establishing routines and action plans, (3) remote glucose monitoring, (4) achievement of glycaemic goals through automation, (5) children/adolescents' capability to use AHCL independently, (6) improved outcomes incentivized continued AHCL, (7) optimism about sustained improvements and (8) social support from healthcare providers, school staff, peers and parents. Barriers to AHCL implementation included the following: (1) challenges with device usability, (2) need for technical support, (3) forgotten knowledge and skills, (4) non-adherence to best practices, (5) negative social influences, (6) physical and psychosocial burden and (7) negative emotions.

CONCLUSIONS

This study provides comprehensive insights into parental perspectives of influences on implementing AHCL therapy in children and adolescents with elevated glycaemia. As parents remain key partners in diabetes care, these findings inform successful implementation of AHCL and development of future diabetes technology.

Time in tight glucose range in adolescents and young adults with diabetes during Ramadan intermittent fasting: Data from real-world users on different treatment strategies

BACKGROUND

Time in tight range (TITR) is a novel glycemic metric assessing normoglycemia in individuals with diabetes.

AIM

To assess the attainability of the TITR (70-140 mg/dL) target in youth with diabetes using different treatment strategies during Ramadan fasting.

METHODS

This prospective study included 276 non-insulin-treated type 2 diabetes mellitus (T2DM) and 426 patients with type 1 diabetes mellitus (T1DM) who were categorized into: multiple daily injections [MDI] + intermittently scanned CGM (isCGM), sensor augmented pump (SAP) and advanced hybrid closed loop (AHCL).

RESULTS

At the end of Ramadan, the mean TITR was 42.3 ± 6.6 % for all T1DM patients and 63.5 ± 4.0 % in T2DM (p < 0.001). The highest TITR was in T2DM group together with T1DM on AHCL (62.3 ± 11.6 %), followed by SAP group (37.7 ± 5.7 %) and MDI + isCGM group (23.6 ± 5.9 %, p < 0.001). Hypoglycemic episodes as shown by time below range (TBR) < 70 mg/dL and TBR < 54 mg/dL were minimal during Ramadan in AHCL group in comparison to before Ramadan (2.6 ± 0.7 versus 2.9 ± 0.9 %; p = 0.061 and 0.4 ± 0.1 vs 0.5 ± 0.1 %, p = 0.561, respectively) with a lower coefficient of variation (CoV) (p < 0.001) than other T1DM participants.

CONCLUSION

At the end of Ramadan, TITR was decreased in patients with T1DM except those using AHCL who had similar levels to non-insulin-treated T2DM patients. Advanced technology has the potential for achieving tight glycemic targets, along with a reduction in CoV, without increasing hypoglycemic risk compared with other insulin treatment modalities.

Simplified meal announcement study (SMASH) using hybrid closed-loop insulin delivery in youth and young adults with type 1 diabetes: a randomised controlled two-centre crossover trial

AIMS/HYPOTHESIS

The majority of hybrid closed-loop systems still require carbohydrate counting (CC) but the evidence for its justification remains limited. Here, we evaluated glucose control with simplified meal announcement (SMA) vs CC in youth and young adults with type 1 diabetes using the mylife CamAPS FX system.

METHODS

We conducted a two-centre, randomised crossover, non-inferiority trial in two University Hospitals in Switzerland in 46 participants (aged 12-20 years) with type 1 diabetes using multiple daily injections (n=35), sensor-augmented pump (n=4) or hybrid closed-loop (n=7) therapy before enrolment. Participants underwent two 3 month periods with the mylife CamAPS FX system (YpsoPump, Dexcom G6) to compare SMA (individualised carbohydrate meal sizes) with CC, in a randomly assigned order using computer-generated sequences. The primary endpoint was the proportion of time glucose was in target range (3.9-10.0 mmol/l) with a non-inferiority margin of 5 percentage points. Secondary endpoints were other sensor glucose and insulin metrics, usability and safety endpoints.

RESULTS

Forty-three participants (18 women and girls) completed the trial. In the intention-to-treat analysis, time in range (mean±SD) was 69.9±12.4% with SMA and 70.7±13.0% with CC (estimated mean difference -0.6 percentage points [95% CI -2.4, 1.1], demonstrating non-inferiority). Time <3.9 mmol/l (median [IQR] 1.8 [1.2-2.2]% vs 1.9 [1.6-2.5]%) and >10.0 mmol/l (28.2±12.6% vs 27.2±13.4%) was similar between periods. Total daily insulin dose was higher with SMA (54.0±14.7 U vs 51.7±12.1 U, p=0.037). Three participants experienced serious adverse events, none of which were intervention-related.

CONCLUSIONS/INTERPRETATION

Glucose control using the CamAPS FX algorithm with SMA was non-inferior to its use with CC in youth and young adults with type 1 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05481034.

FUNDING

The study was supported by the Swiss Diabetes Foundation and by a YTCR grant from the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences. Dexcom and Ypsomed provided product support.

Experiences of adolescents and young adults with type 1 diabetes and chronically elevated glucose levels following the transition from multiple daily injections to advanced hybrid closed-loop: A qualitative study

AIM

To understand experiences of using second-generation advanced hybrid closed-loop (AHCL) therapy in adolescents and young adults with chronically elevated glucose levels who were previously using multiple daily injections (MDI) therapy.

METHOD

Semi-structured interviews with participants aged 13-25 years, on AHCL therapy for 3 months as part of a single-arm prospective study. Key inclusions: HbA1c ≥69 mmol/mol (8.5%); diabetes duration ≥1 year; and using MDI therapy prior to the study. Qualitative content analysis was used to identify themes and subthemes.

RESULTS

Interviews were conducted among 14 participants with mean age 19.4 ± 4.3 years and mean baseline HbA1c 90 ± 25 mmol/mol (10.4 ± 4.5%). Three themes were identified: (1) substantially improved glucose levels improved perceptions of overall health; (2) features of AHCL aid in adoption and ongoing self-management; and (3) burden of care was reduced through automation of insulin delivery. Overall, there were positive impacts on physical, mental and social well-being. Participants were willing to overlook minor frustrations with AHCL because of the vast benefits that they had experienced. Four participants reported transient pseudo-hypoglycaemia: symptoms of hypoglycaemia when objectively measured glucose was in the clinically recommended range (3.9-10 mmol/L, 70-180 mg/dL).

CONCLUSION

Transition to AHCL therapy positively impacted diabetes management in adolescents and youth with chronically elevated glucose levels. It appears to create a window of opportunity in which youth may re-engage with diabetes management. Pseudo-hypoglycaemia can occur during the transition to AHCL. This could be a barrier to AHCL uptake and is likely to require individualised support.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Bajaj M, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Ekhlaspour L, Gaglia JL, Garg R, Girotra M, Khunti K, Lal R, Lingvay I, Matfin G, Neumiller JJ, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Bannuru RR. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Navigating the Unique Challenges of Automated Insulin Delivery Systems to Facilitate Effective Uptake, Onboarding, and Continued Use

Advances in diabetes technologies have enabled automated insulin delivery (AID) systems, which have demonstrated benefits to glycemia, psychosocial outcomes, and quality of life for people with type 1 diabetes (T1D). Despite the many demonstrated benefits, AID systems come with their own unique challenges: continued user attention and effort, barriers to equitable access, personal costs vs benefits, and integration of the system into daily life. The purpose of this narrative review is to identify challenges and opportunities for supporting uptake and onboarding of AID systems to ultimately support sustained AID use. Setting realistic expectations, providing comprehensive training, developing willingness to adopt new treatments and workflows, upskilling of diabetes team members, and increasing flexibility of care to tailor care to individual needs, preferences, lifestyle, and personal goals will be most effective in facilitating effective, widespread, person-centered implementation of AID systems.

Simplified Meal Management in Adults Using an Advanced Hybrid Closed-Loop System

Background: The advanced hybrid closed-loop (AHCL) algorithm combines automated basal rates and corrections yet requires meal announcement for optimal performance, which poses a challenge for some. We aimed to compare glucose control in adults with type 1 diabetes (T1D) using the MiniMedTM 780G AHCL system, utilizing simplified meal announcement versus precise carbohydrate (CHO) counting. Methods: In a study involving 14 adults with T1D, we evaluated glycemic control during a 13-week "precise phase," followed by two 3- to 4-week simplified meal announcement phases: "fixed one-step" (preset of one personalized fixed CHO amount) and "multistep" (entry of multiples of one, two, or three of these presets depending on meal size estimate). Results: The mean age was 45.7 ± 12.4, and 10 participants were male (71%). Mean baseline HbA1c was 6.8% ± 1.2% and time in range (TIR) was 67.5% ± 16.7%. Comparing the fixed one-step to the precise study phase, TIR was similar (75.4 ± 13% vs. 77.7 ± 9%, P = 0.12), and glucose management indicator (GMI) was slightly higher (6.8 ± 0.4 vs. 6.6 ± 0, P = 0.01). Furthermore, there was less level 1 and 2 hypoglycemia (1.6 ± 1% vs. 2.8 ± 2%, P = 0.03 and 0.3 ± 5% vs. 0.65 ± 1%, P = 0.08) but slightly more level 1 and 2 hyperglycemia (17.1 ± 8% vs. 15.0 ± 7%, P = 0.05 and 5.5 ± 5% vs. 3.6 ± 3%, P = 0.04). When comparing the multistep with the precise phase, GMI was identical (6.6%) and TIR superior (80.5 ± 10% vs. 77.7 ± 9%, P = 0.02). Additionally, there was less level 1 hypoglycemia (1.9 ± 1% vs. 2.8 ± 2%, P = 0.01) and a trend for less level 2 hypoglycemia (0.4 ± 0.7% vs. 0.65 ± 1%, P = 0.08). Conclusions: A simplified meal announcement strategy for adults using the MiniMed 780G system, relying on three increments of a fixed one-step CHO amount, may offer a way to improve glycemic control and ease self-care. For patients with more limitations, using one fixed one-step CHO amount could be a safe alternative to meeting most consensus glycemic targets.

The success of insulin pump therapy: importance of education of patients and health professionals

The purpose of the study is to investigate the importance of education and re-education for the proper use of the insulin pump (IP) in order to maintain stable glycemic control over an extended period.

Methods

The study was designed as a cross-sectional retrospective study. A total of 168 patients participated in a five-day structured education program in a small group. Following the initial education, 42 patients who met the criteria for continuation of IP treatment continued to be monitored every six months (period I). After six years of follow-up (period II) data from 36 patients were taken and analyzed. The data from the IP were downloaded from the IP Paradigm 754 "VEO" (Medtronic Inc., Illinois, USA) on the personal computer via the CareLink Pro software (Medtronic, Inc., Illinois).

Results

The number of patients using the bolus calculator (BC+) for at least 50% of all administered boluses remained high in both periods. However, BC+ patients statistically significantly increased their A1C value in period II. The average number of hypoglycemias was statistically significantly increased in the group of BC+ patients in period II compared to period I (p=0.009). The continuous glucose monitors (CGM) were used only in period II, so the number of hypoglycemias in period I were roughly estimated.

Conclusions

The long-term success of IP therapy primary depends on the proper use of the device, highlighting the importance of good education and regular re-education for both patients and health professionals. Advanced hybrid technology systems could be particularly in settings with poorly organized healthcare, where re-education is not routinely provided and diabetes control relies heavily on the patient engagement.

Comparing the Effectiveness of Different Dietary Educational Approaches for Carbohydrate Counting on Glycemic Control in Adults with Type 1 Diabetes: Findings from the DIET-CARB Study, a Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Carbohydrate counting is recommended to improve glycemic control in type 1 diabetes (T1D), but the most effective educational methods are unclear. Despite its benefits, many individuals struggle with mastering carbohydrate counting, leading to inconsistent use and suboptimal glycemic outcomes. This study aimed to compare the effectiveness of two group-based programs with individual dietary counseling (standard care) for glycemic control.

METHODS

The trial was a randomized, controlled, open-label, parallel-group design. Adults with T1D on multiple daily insulin injections (MDIs) and with glycated hemoglobin A1c (HbA1c) 53-97 mmol/mol were randomly assigned (1:1:1) to basic (BCC), advanced carbohydrate counting (ACC), or standard care. Primary outcomes were the changes in HbA1c or mean amplitude of glycemic excursions (MAGEs) in BCC and ACC versus standard care after six months. Equivalence testing was performed to compare BCC and ACC.

RESULTS

Between November 2018 and August 2021, 63 participants were randomly assigned to BCC (N = 20), ACC (N = 21), or standard care (N = 22). After 6 months, HbA1c changed by -2 mmol/mol (95% CI -5 to 0 [-0.2%, -0.5 to 0]) in BCC, -4 mmol/mol (-6 to -1 [-0.4%, -0.6 to -0.1]) in ACC, and -3 mmol/mol (-6 to 0 [-0.3%, -0.6 to 0]) in standard care. The estimated difference in HbA1c compared to standard care was 1 mmol/mol (-3 to 5 [0.1%, -0.3 to 0.5]); p = 0.663 for BCC and -1 mmol/mol (-4 to 3 [-0.1%, -0.4 to 0.3]); p = 0.779 for ACC. For MAGEs, changes were -0.3 mmol/L (-1.5 to 0.8) in BCC, -0.0 mmol/L (-1.2 to 1.1) in ACC, and -0.7 mmol/L (-1.8 to 0.4) in standard care, with differences of 0.4 mmol/L (-1.1 to 1.9); p = 0.590 for BCC and 0.7 mmol/L (-0.8 to 2.1); p = 0.360 for ACC versus standard care. An equivalence in effect between BCC and ACC was found for HbA1c, but not for MAGEs.

CONCLUSIONS

Group-based education in BCC and ACC did not demonstrate a clear advantage over individualized dietary counseling for overall glycemic control in adults with T1D. Healthcare providers should consider flexible, patient-centered strategies that allow individuals to choose the format that best suits their learning preferences when selecting the most suitable dietary educational approach.

Excellence in the management of Advanced Hybrid Closed-Loop Systems: Lessons from the Polish cohort

BACKGROUND

The aim of the study was to analyze the real-world performance of MiniMed 780G (MM780G) Advanced Hybrid Closed Loop (AHCL) system users from Poland (PL) and compare it to the European region excluding Poland (EU-PL) in order to identify factors contributing to potential differences. The former achieved some of the best Time in Range (TIR) results globally using this technology.

METHODS

CareLink Personal data uploaded by MM780G system users from August 2020 to December 2022 were analyzed.

RESULTS

The Polish users (N=1304) on average reached to TIR of 79.1 ± 8.7 % (vs 73.0 ± 10.0 % for EU-PL, N=55659), a TBR<54 mg/dL of 0.6 ± 0.7 % (vs 0.4 ± 0.6 %) and a TBR<70 mg/dL of 2.9 ± 2.1 % (vs 2.1 ± 1.8 %). The adoption rate of optimal settings (i.e, GT=100 mg/dL, AIT=2hr) in PL was high (19.7 % vs 6.3 %), and filtering on optimal setting users led to less pronounced differences in glycemic control between PL and EU-PL. A univariable analysis with post-AHCL TIR showed that geography itself (PL vs EU-PL) is not a significant contributor to a high post-AHCL TIR (p = 0.15), and that much of the Polish post-AHCL TIR can be explained by the high pre-AHCL TIR.

CONCLUSION

The Polish MM780G users achieved better glycemic control than the general European population (excluding Poland). This is largely attributable to the adoption of optimal settings in Poland and the already high glycemic outcomes at system start. As these characteristics can be implemented elsewhere, we believe this outstanding result can be obtained in other countries as well.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Comparison of Metabolic Control in Children and Adolescents Treated with Insulin Pumps

BACKGROUND

While insulin pumps remain the most common form of therapy for youths with type 1 diabetes (T1DM), they differ in the extent to which they utilize data from continuous glucose monitoring (CGM) and automate insulin delivery.

METHODS

The aim of the study was to compare metabolic control in patients using different models of insulin pumps. This retrospective single-center study randomly sampled 30 patients for each of the following treatments: Medtronic 720G without PLGS (predictive low glucose suspend), Medtronic 640G or 740G with PLGS and Medtronic 780G. In the whole study group, we used CGM systems to assess patients' metabolic control, and we collected lipid profiles. In three groups of patients, we utilized CGM sensors (Guardian 3, Guardian 4, Libre 2 and Dexcom G6) to measure the following glycemic variability proxy values: time in range (TIR), time below 70 mg/dL (TBR), time above 180 mg/dL (TAR), coefficient of variation (CV) and mean sensor glucose.

RESULTS

Medtronic 640G or 740G and 780G users were more likely to achieve a target time in the target range 70-180 mg/dL (≥80%) [Medtronic 720G = 4 users (13.3%) vs. Medtronic 640G/740G = 10 users (33.3%) vs. Medtronic 780G = 13 users (43.3%); p = 0.0357)] or low glucose variability [Medtronic 720G = 9 users (30%) vs. Medtronic 640G/740G = 18 users (60%) vs. Medtronic 780G = 19 users (63.3%); p = 0.0175)].

CONCLUSIONS

Any integration between the insulin pump and CGM was associated with better glycemic control. More advanced technologies and artificial intelligence in diabetes help patients maintain better glycemia by eliminating various factors affecting postprandial glycemia.

Ten Years of Improving Glycemic Control in Pediatric Diabetes Care: Data From the Norwegian Childhood Diabetes Registry

OBJECTIVE

To evaluate, from 2013 to 2022, how HbA1c, the incidence of acute complications, and use of diabetes technology changed at the national level in Norway and how glycemic control was associated with use of diabetes technology, carbohydrate counting, or participation in a quality improvement project.

RESEARCH DESIGN AND METHODS

This longitudinal observational study was based on 27,214 annual registrations of 6,775 children from the Norwegian Childhood Diabetes Registry from 2013 to 2022. Individuals aged >18 years, those with diabetes other than type 1, and those without HbA1c measurements were excluded. The outcome measure was HbA1c. The predictor variables in the adjusted linear mixed-effects model were 1) the use of diabetes technology, 2) the use of carbohydrate counting for meal bolusing, and 3) whether the patient's diabetes team participated in a quality improvement project.

RESULTS

Mean HbA1c decreased from 8.2% (2013) to 7.2% (2021), and the proportion of youth reaching an HbA1c <7.0% increased from 13% (2013) to 43% (2022). Insulin pump use increased from 65% (2013) to 91% (2022). Continuous glucose monitoring (CGM) use increased from 34% (first recorded in 2016) to 97% (2022). Insulin pump, CGM, and carbohydrate counting were associated with lower HbA1c and higher achievement of glycemic targets. Girls had a higher mean HbA1c than boys. Mean HbA1c levels were lower in clinics that participated in a quality improvement project for the following 4 years after the project.

CONCLUSIONS

Diabetes technology, carbohydrate counting, and systematic quality improvement in pediatric departments led to improved glycemic control.

Simple meal announcements and pramlintide delivery versus carbohydrate counting in type 1 diabetes with automated fast-acting insulin aspart delivery: a randomised crossover trial in Montreal, Canada

BACKGROUND

In type 1 diabetes, carbohydrate counting is the standard of care to determine prandial insulin needs, but it can negatively affect quality of life. We developed a novel insulin-and-pramlintide closed-loop system that replaces carbohydrate counting with simple meal announcements.

METHODS

We performed a randomised crossover trial assessing 14 days of (1) insulin-and-pramlintide closed-loop system with simple meal announcements, (2) insulin-and-placebo closed-loop system with carbohydrate counting, and (3) insulin-and-placebo closed-loop system with simple meal announcements. Participants were recruited at McGill University Health Centre (Montreal, QC, Canada). Eligible participants were adults (aged ≥18 years) and adolescents (aged 12-17 years) with type 1 diabetes for at least 1 year. Participants were randomly assigned in a 1:1:1:1:1:1 ratio to a sequence of the three interventions, with faster insulin aspart used in all interventions. Each intervention was separated by a 14-45-day wash-out period, during which participants reverted to their usual insulin. During simple meal announcement interventions, participants triggered a prandial bolus at mealtimes based on a programmed fixed meal size, whereas during carbohydrate counting interventions, participants manually entered the carbohydrate content of the meal and an algorithm calculated the prandial bolus based on insulin-to-carbohydrate ratio. Two primary comparisons were predefined: the percentage of time in range (glucose 3·9-10·0 mmol/L) with a non-inferiority margin of 6·25% (non-inferiority comparison); and the mean Emotional Burden subscale score of the Diabetes Distress Scale (superiority comparison), comparing the insulin-and-placebo system with carbohydrate counting minus the insulin-and-pramlintide system with simple meal announcements. Analyses were performed on a modified intention-to-treat basis, excluding participants who did not complete all interventions. Serious adverse events were assessed in all participants. This trial is registered on ClinicalTrials.gov, NCT04163874.

FINDINGS

32 participants were enrolled between Feb 14, 2020, and Oct 5, 2021; two participants withdrew before study completion. 30 participants were analysed, including 15 adults (nine female, mean age 39·4 years [SD 13·8]) and 15 adolescents (eight female, mean age 15·7 years [1·3]). Non-inferiority of the insulin-and-pramlintide system with simple meal announcements relative to the insulin-and-placebo system with carbohydrate counting was reached (difference -5% [95% CI -9·0 to -0·7], non-inferiority p<0·0001). No statistically significant difference was found in the mean Emotional Burden score between the insulin-and-pramlintide system with simple meal announcements and the insulin-and-placebo system with carbohydrate counting (difference 0·01 [SD 0·82], p=0·93). With the insulin-and-pramlintide system with simple meal announcements, 14 (47%) participants reported mild gastrointestinal symptoms and two (7%) reported moderate symptoms, compared with two (7%) participants reporting mild gastrointestinal symptoms on the insulin-and-placebo system with carbohydrate counting. No serious adverse events occurred.

INTERPRETATION

The insulin-and-pramlintide system with simple meal announcements alleviated carbohydrate counting without degrading glucose control, although quality of life as measured by the Emotional Burden score was not improved. Longer and larger studies with this novel approach are warranted.

FUNDING

Juvenile Diabetes Research Foundation.

Time in Tight Glucose Range in Type 1 Diabetes: Predictive Factors and Achievable Targets in Real-World Users of the MiniMed 780G System

OBJECTIVE

We studied time in tight range (TITR) (70-140 mg/dL) in real-world users of the MiniMed 780G system (MM780G).

RESEARCH DESIGN AND METHODS

CareLink Personal data were extracted (August 2020 to December 2022) to examine TITR and its relationship with time in range (TIR; 70-180 mg/dL), factors predicting higher TITR, and which TITR target is a reasonable treatment goal.

RESULTS

The 13,461 users (3,762 age ≤15 years and 9,699 age >15 years) showed an average TITR of 48.9% in those age ≤15 years and 48.8% in the older group (vs. TIR 71.2% and 73.9%, respectively). Consistent use of a glucose target (GT) of 100 mg/dL and active insulin time (AIT) of 2 h were the most relevant factors predicting higher TITR (P < 0.0001). In users consistently applying these optimal settings, TITR was 56.7% in those age ≤15 years and 57.0% in the older group, and the relative impact of these settings on TITR was 60% and 86% greater than that on TIR, respectively. TITRs of ∼45% (age ≤15 years 46.3% and older group 45.4%), ∼50% (50.7% and 50.7%) and ∼55% (56.4% and 58.0%) were best associated with glucose management indicators <7.0%, <6.8%, and <6.5%, respectively. TITRs of >45%, >50%, and >55% were achieved in 91%, 74%, and 55% of those age ≤15 years and 93%, 81%, and 57% of older group users, respectively, at optimal settings.

CONCLUSIONS

This study demonstrates that 1) mean TIR is high with a high mean TITR in MM780G users (>48%), 2) consistent use of optimal GT/AIT improves TITR (>56%), 3) the impact of these settings on TITR is larger than on TIR, and 4) a TITR target >50% is our suggested treatment goal.

Optimal Coefficient of Variance Threshold to Minimize Hypoglycemia Risk in Individuals with Well-Controlled Type 1 Diabetes Mellitus

BACKGRUOUND

This study investigated the optimal coefficient of variance (%CV) for preventing hypoglycemia based on real-time continuous glucose monitoring (rt-CGM) data in people with type 1 diabetes mellitus (T1DM) already achieving their mean glucose (MG) target.

METHODS

Data from 172 subjects who underwent rt-CGM for at least 90 days and for whom 439 90-day glycemic profiles were available were analyzed. Receiver operator characteristic analysis was conducted to determine the cut-off value of %CV to achieve time below range (%TBR)<54 mg/dL <1 and =0.

RESULTS

Overall mean glycosylated hemoglobin was 6.8% and median %TBR<54 mg/dL was 0.2%. MG was significantly higher and %CV significantly lower in profiles achieving %TBR<54 mg/dL <1 compared to %TBR<54 mg/dL ≥1 (all P<0.001). The cut-off value of %CV for achieving %TBR<54 mg/dL <1 was 37.5%, 37.3%, and 31.0%, in the whole population, MG >135 mg/dL, and ≤135 mg/dL, respectively. The cut-off value for %TBR<54 mg/dL=0% was 29.2% in MG ≤135 mg/dL. In profiles with MG ≤135 mg/dL, 94.2% of profiles with a %CV <31 achieved the target of %TBR<54 mg/dL <1, and 97.3% with a %CV <29.2 achieved the target of %TBR<54 mg/ dL=0%. When MG was >135 mg/dL, 99.4% of profiles with a %CV <37.3 achieved %TBR<54 mg/dL <1.

CONCLUSION

In well-controlled T1DM with MG ≤135 mg/dL, we suggest a %CV <31% to achieve the %TBR<54 mg/dL <1 target. Furthermore, we suggest a %CV <29.2% to achieve the target of %TBR<54 mg/dL =0 for people at high risk of hypoglycemia.

Lived Experience of Fully Closed-Loop Insulin Delivery in Adults with Type 1 Diabetes

Introduction: The Closing the Loop in Adults With Type 1 Diabetes (CLEAR) randomized crossover study compared a novel fully closed-loop insulin delivery system with no carbohydrate entry or mealtime bolusing (CamAPS HX), with standard insulin pump therapy and glucose sensor in adults with type 1 diabetes and suboptimal glycemic outcomes. This qualitative substudy aimed to understand the psychosocial impact of using the fully automated system. Materials and Methods: Adults participating in the CLEAR study were invited to take part in a virtual semistructured interview after they had completed 8 weeks using the fully closed-loop system. Recruitment continued until there was adequate representation and data saturation occurred. Interviews were anonymized and transcribed for in-depth thematic analysis using an inductive-deductive approach. Study participants were also asked to complete questionnaires assessing diabetes distress, hypoglycemia confidence, and closed-loop treatment satisfaction. Results: Eleven participants (eight male and three female; age range 26-66 years) were interviewed. After an initial adjustment period, interviewees reported enjoying a reduction in diabetes burden, freed-up mental capacity, and improved mood. All were happy with overnight glycemic outcomes, with the majority reporting benefits on sleep. Although experiences of postprandial glucose outcomes varied, all found mealtimes easier and less stressful, particularly when eating out. Negatives raised by participants predominantly related to the insulin pump hardware, but some also reported increased snacking and challenges around resuming carbohydrate counting at trial closeout. Conclusions: In adults with type 1 diabetes, use of a fully closed-loop insulin delivery system had significant quality-of-life benefits and provided a welcome break from the day-to-day demands of living with diabetes. Clinical Trial Registration: NCT04977908.

Basic carbohydrate counting and glycemia in young people with type 1 diabetes in India: A randomized controlled trial

OBJECTIVES

The aim of this study was to evaluate the effect on glycemic control and acceptability of basic carbohydrate counting (BCC) in children and young adults with type 1 diabetes (T1DM).

METHODS

Ninety-two children and young adults (6-25 y of age) with T1DM were randomized to receive either routine nutrition education (RNE), which addressed food groups, glycemic index, and effects of food and exercise on glycemia, or learn BCC with personalized portion size education. A continuous glucose monitoring study and glycosylated hemoglobin (HbA1c) were performed at baseline and after 12 wk. The primary outcome was a change in time-in-range from baseline through 12 wk. A questionnaire on the acceptability of BCC was administered.

RESULTS

At 12 wk, there was no significant difference in change in time-in-range between the two groups (BCC group: 1.2 ± 12.2; RNE group: 1.9 ± 12.3; P = 0.786). No significant changes were observed in the percentage of time that blood glucose was >180 or >250 mg/dL; <70 or <54 mg/dL; glycemic variability, percentage of nights with hypoglycemia and HbA1c. In subgroup analysis, there was a significant decrease in HbA1c in the BCC group among participants with higher maternal education (-0.5 versus 0.2, P = 0.042). The total score on the acceptability questionnaire was higher in the BCC group (P = 0.022).

CONCLUSION

Among children and young adults in our region with T1DM, BCC provided flexibility in food choices and perception of greater ease of insulin adjustment. Although BCC was equivalent to RNE in terms of glycemic control, larger studies may reveal benefit in outcomes in certain subgroups.

Future of Time-in-Range Goals in the Era of Advanced Hybrid Closed-Loop Automated Insulin Delivery Systems

The concept of maintaining blood glucose levels within the 70-180 mg/dL range, known as time-in-range, has raised questions regarding its representation of true physiological euglycemia. Some have speculated that focusing on the time spent within the 70-140 mg/dL range, introduced as time in tight range (TITR) through the International Consensus statement, could serve as a more precise metric for assessing normoglycemia in individuals with type 1 diabetes. This article delves into the current status of TITR as an emerging marker and explores how advanced hybrid closed-loop systems may offer a promising avenue for achieving this higher level of glycemic control.

Early Real-World Performance of the MiniMed™ 780G Advanced Hybrid Closed-Loop System and Recommended Settings Use in the United States

Background: The MiniMed™ 780G system (MM780G) with Guardian™ 4 sensor includes a 100 mg/dL glucose target (GT) and automated insulin corrections up to every 5 min and was recently approved for use in the United States. In the present study, early real-world MM780G performance and the use of recommended system settings (100 mg/dL GT with an active insulin time of 2 h), by individuals with type 1 diabetes, were evaluated. Methods: CareLink™ personal data uploaded between the launch of the MM780G to August 22, 2023 were aggregated and underwent retrospective analysis (based on user consent) and if users had ≥10 days of continuous glucose monitoring (CGM) data. The 24-h day CGM metrics, including mean glucose, percentage of time spent in (%TIR), above (%TAR), and below (%TBR) target range (70-180 mg/dL), in addition to delivered insulin and closed-loop (CL) exits, were compared between an overall group (n = 7499) and individuals who used recommended settings (each, for >95% of the time). An analysis of the same metrics for MiniMed™ 770G system (MM770G) users (n = 3851) who upgraded to the MM780G was also conducted (paired t-test or Wilcoxon signed-rank test, P < 0.05 considered statistically significant). Results: For MM780G users, CGM use, and time in CL were >90% and all MM780G CGM metrics exceeded consensus-recommended goals. With recommended settings (22% of all users), mean %TIR and %TITR (70-140 mg/dL) were 81.4% and 56.4%, respectively. For individuals who upgraded from the MM770G, %TIR and %TITR increased from 73.2% to 78.3% and 45.8% to 52.6%, respectively, while %TAR reduced from 25.1% to 20.2% (P < 0.001, for all three). CL exits/week averaged <1, for all MM780G users. Conclusions: Early real-world MM780G use in the United States demonstrated a high percentage of time in range with low time above and below range. These outcomes are similar to those observed for real-world MM780G use in other countries.

Emerging Technologies and Therapeutics for Type 1 Diabetes

Recent years witnessed advancements in diabetes technologies and therapeutics. People with type 1 diabetes have more options to control their blood glucose, prevent hypoglycemia, and spend more time with their loved ones. Newer diabetes technologies and therapeutics improve the quality of life and boost the confidence of people with type 1 diabetes. In parallel to changes in the diabetes technology field, stem cell research has been evolving. Gene editing and production of β cells from stem cells are ongoing. The current focus of cure studies is how to increase the survival of cells produced with stem cells. New adjunctive therapies are under development.

Removing Barriers, Bridging the Gap, and the Changing Role of the Health Care Professional with Automated Insulin Delivery Systems

As all people with type 1 diabetes (T1D) and some with type 2 diabetes (T2D) require insulin, there is a need to develop management methods that not only achieve glycemic targets but also reduce the burden of living with diabetes. After insulin pumps and continuous glucose monitors, the next step in the evolution of diabetes technology is automated insulin delivery (AID) systems, which have transformed intensive insulin management over the past decade, as these systems address the shortcomings of previous management options. However, AID use remains fairly limited, and access represents a major barrier to use for many people with diabetes, despite these systems being standard of care. Therefore, the future of AID will necessitate addressing barriers related to social determinants of health, finances, and an expansion of the number and type of health care professionals (HCPs) prescribing AID systems. These crucial steps will be essential to ensure that everyone with intensively managed diabetes can use AID systems. The impact of implementing these changes will create a shift in the future of diabetes care that will result in achievement of more targeted glycemia and psychosocial outcomes for all people with diabetes and an expansion of the role of all HCPs in AID-related diabetes care. Even more importantly, by addressing social determinants of health and clinical inertia related to AID, the field can address disparities in outcomes across countries, race, gender, socioeconomic status, and insurance status. Furthermore, the increased use of AID system will provide more time during appointments for a shift in the discussion away from fine tuning insulin dosing and toward a focus on more topics related to behavior and conversations about general health. This will include psychosocial outcomes, and quality of life. In addition, these changes can hopefully allow for time to discuss more general issues, such as cardiovascular health, obesity prevention, diabetes-related complications, and other health-related concerns.

Twelve-Month Follow-up from a Randomized Controlled Trial of Simplified Meal Announcement Versus Precise Carbohydrate Counting in Adolescents with Type 1 Diabetes Using the MiniMed™ 780G Advanced Hybrid Closed-Loop System

Background and Aims: Carbohydrate counting is a well-established tool for self-management of type 1 diabetes (T1D) and can improve glycemic control and potentially reduce long-term complication risk. However, it can also be burdensome, error-prone, and complicated for the patient. A randomized controlled trial was conducted to investigate glycemic control with carbohydrate counting ("flex") versus simplified meal announcement ("fix") in adolescents with T1D using the MiniMed™ 780G system. The present study reports follow-up data to 12 months. Methods: Adolescents with T1D were randomly assigned 1:1 to use the MiniMed™ 780G system alongside the flex versus fix approaches. Participants were followed for 12 months with outcomes recorded at 3, 6, 9, and 12 months. The primary endpoint was the difference in time-in-range (TIR), and secondary endpoints included glycated hemoglobin (HbA1c) and other glucose and insulin metrics. Results: At 12 months, TIR (proportion of time with sensor glucose 70-180 mg/dL) was significantly lower in the fix versus flex group (72.9% vs. 80.1%, respectively; P = 0.001). There was no significant difference in HbA1c between the fix (6.8% ± 0.5%) and flex groups (6.5% ± 0.5%) at 12 months (P = 0.092), and mean HbA1c was below 7% at all time points in both arms. Conclusions: Glycemic control with simplified meal announcement was maintained over 12 months. On average, the international consensus targets were met in both arms for all time points. The simplified approach represents a viable alternative to carbohydrate counting, particularly in people who find the latter burdensome; however, carbohydrate counting resulted in superior TIR. This study is registered with ClinicalTrials.gov, number NCT05069727.

A Peek Under the Hood: Explaining the MiniMed™ 780G Algorithm with Meal Detection Technology

The MiniMed™ 780G system (780G) received Conformité Européenne mark in June 2020 and was, recently, approved by the U.S. Food and Drug Administration (April 2023). Clinical trials and real-world analyses have demonstrated MiniMed™ 780G system safety and effectiveness and that glycemic outcomes (i.e., time in range) improve with recommended settings use. In this publication, we will explain the iterative development of the 780G algorithm and how this technology has simplified diabetes management.

Postprandial glucose metabolism in children and adolescents with type 1 diabetes mellitus: potential targets for improvement

The main goal of therapeutic management of type 1 Diabetes Mellitus (T1DM) is to maintain optimal glycemic control to prevent acute and long-term diabetes complications and to enable a good quality of life. Postprandial glycemia makes a substantial contribution to overall glycemic control and variability in diabetes and, despite technological advancements in insulin treatments, optimal postprandial glycemia is difficult to achieve. Several factors influence postprandial blood glucose levels in children and adolescents with T1DM, including nutritional habits and adjustment of insulin doses according to meal composition. Additionally, hormone secretion, enteroendocrine axis dysfunction, altered gastrointestinal digestion and absorption, and physical activity play important roles. Meal-time routines, intake of appropriate ratios of macronutrients, and correct adjustment of the insulin dose for the meal composition have positive impacts on postprandial glycemic variability and long-term cardiometabolic health of the individual with T1DM. Further knowledge in the field is necessary for management of all these factors to be part of routine pediatric diabetes education and clinical practice. Thus, the aim of this report is to review the main factors that influence postprandial blood glucose levels and metabolism, focusing on macronutrients and other nutritional and lifestyle factors, to suggest potential targets for improving postprandial glycemia in the management of children and adolescents with T1DM.

Safety, Metabolic and Psychological Outcomes of Medtronic MiniMed 780G™ in Children, Adolescents and Young Adults: A Systematic Review

The MiniMed™ 780G is a second-generation automated insulin delivery system that implements a modified proportional-integral-derivative algorithm with some features of an MD-Logic artificial pancreas algorithm. The system may deliver automatic correction boluses up to every 5 min, and it allows the user to choose between three glucose target setpoints (100, 110 and 120 mg/dL). We aimed to review the current evidence on this device in children, adolescents, and young adults living with type 1 diabetes. We screened 783 papers, but only 31 manuscripts were included in this review. Data on metabolic outcomes show that this system is safe as regards severe hypoglycaemia and diabetic ketoacidosis. The glycated haemoglobin may drop to levels about 7%, with CGM reports showing a time in range of 75-80%. The time above range and the time below range are within the recommended target in most of the subjects. Few studies evaluated the psychological outcomes. This system seems to be more effective than the first-generation automated insulin delivery systems. The MiniMed™ 780G has been associated with an improvement in sleep quality in subjects living with diabetes and their caregivers, along with an improvement in treatment satisfaction. Psychological distress is as reduced as the glucose control is improved. We also discuss some case reports describing particular situations in clinical practice. Finally, we think that data show that this system is a further step towards the improvement of the treatment of diabetes as concerns both metabolic and psychological outcomes.

Glucose and Psychosocial Outcomes 12 Months Following Transition from Multiple Daily Injections to Advanced Hybrid Closed Loop in Youth with Type 1 Diabetes and Suboptimal Glycemia

Objective: To investigate 12-month glycemic and psychosocial changes following transition from multiple daily injections (MDI) to advanced hybrid closed-loop (AHCL) therapy in youth (aged 13-25 years) with type 1 diabetes and suboptimal glycemia (glycated hemoglobin [HbA1c] ≥8.5% [69 mmol/mol]). Research Design and Methods: Prospective, single arm, dual-center study in 20 participants. Extension phase outcomes reported after 12 months, including HbA1c, time in glycemic ranges, AHCL system performance, and psychosocial questionnaires assessing quality of life, diabetes treatment, and sleep. Results: After 12 months, 19 out of 20 participants continued to use AHCL. Average time-in-range 70-180 mg/dL (3.9-10.0 mmol/L) improved from 27.6% ± 13.2% to 62.5% ± 11.4%. This translated to an average 2.5 percentage-point (27.1 mmol/mol) improvement in HbA1c from 10.5% ± 2.1% (91.2 mmol/mol) at baseline to 8.0% ± 0.9% (64.1 mmol/mol) at 12 months. Psychosocial questionnaires and very high HbA1c at study entry indicated significant diabetes-associated burden for both individuals and parents. After 12 months, improvements were observed in general and diabetes-specific health-related quality of life, as well as in diabetes treatment satisfaction. Safety data were reassuring with a diabetic ketoacidosis rate of 0.15 per participant-year after 12 months of AHCL (compared to 0.25 per participant-year in the 12 months before the study). Conclusions: After 12 months of AHCL usage, this study highlights the potential for substantial and sustained glycemic and psychosocial improvements among individuals experiencing considerable diabetes burden and suboptimal glycemia, following their switch from MDI to AHCL.

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Gaglia JL, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Guidelines of the Polish Society of Pediatric Endocrinology and Diabetology and Pediatric Section of Diabetes Poland on insulin therapy using hybrid closed-loop systems in children and adolescents with diabetes in Poland

Currently, hybrid closed loop (HCL) systems represent the most advantageous therapeutic option for people with diabetes requiring intensive insulin therapy. They make it possible to achieve optimal metabolic control of the disease in any age group while improving the quality of life of children and adolescents with diabetes and their families. Therefore, we present recommendations for the use of HCL systems in children and adolescents focusing on systems currently available in Poland. These systems should be the first choice in terms of method of insulin therapy in the paediatric population. They can be implemented at any stage of diabetes management. These recommendations are based on scientific evidence and experts' experience. They include principles for the initiation, optimisation, and ongoing management of HCL therapy, as well as the required HCL-related education.

Mitigating iftar-related glycemic excursions in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed loop system: a randomized clinical trial for adjunctive oral vildagliptin therapy during Ramadan fasting

BACKGROUND

Ramadan Iftar meal typically causes glucose excursions. Dipeptidyl peptidase-4 inhibitors increase glucagon-like peptide-1 and thus, decrease blood glucose levels with low risk of hypoglycemia.

AIM

To investigate the efficacy and safety of vildagliptin as an add-on therapy on glucose excursions of Iftar Ramadan meals among adolescents and young adults with type 1 diabetes mellitus (T1DM) using advanced hybrid closed-loop (AHCL) treatment.

METHODS

Fifty T1DM patients on MiniMed™ 780G AHCL were randomly assigned either to receive vildagliptin (50 mg tablet) with iftar meal during Ramadan month or not. All participants received pre-meal insulin bolus based on insulin-to-carbohydrate ratio (ICR) for each meal constitution.

RESULTS

Vildagliptin offered blunting of post-meal glucose surges (mean difference - 30.3 mg/dL [- 1.7 mmol/L] versus - 2.9 mg/dL [- 0.2 mmol/L] in control group; p < 0.001) together with concomitant exceptional euglycemia with time in range (TIR) significantly increased at end of Ramadan in intervention group from 77.8 ± 9.6% to 84.7 ± 8.3% (p = 0.016) and time above range (180-250 mg/dL) decreased from 13.6 ± 5.1% to 9.7 ± 3.6% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in automated daily correction boluses and total bolus dose by 23.9% and 16.3% (p = 0.015 and p < 0.023, respectively) with less aggressive ICR settings within intervention group at end of Ramadan. Coefficient of variation was improved from 37.0 ± 9.4% to 31.8 ± 7.1%; p = 0.035). No severe hypoglycemia or diabetic ketoacidosis were reported.

CONCLUSION

Adjunctive vildagliptin treatment mitigated postprandial hyperglycemia compared with pre-meal bolus alone. Vildagliptin significantly increased TIR while reducing glycemic variability without compromising safety. Trial registration This trial was registered under ClinicalTrials.gov Identifier no. NCT06021119.

Glycemic Control, Basal/Bolus Distribution, BMI and Meal Management in Children and Adolescents with Type 1 Diabetes and Advanced Hybrid Closed Loop

Evidence about the impact of advanced hybrid closed loop (AHCL) on body mass index (BMI) and eating habits in children with type 1 diabetes (T1D) is lacking. This real-world study aimed at evaluating glycemic control, BMI, meals and basal/bolus distribution in young subjects with T1D treated by AHCL. Glycemic metrics, HbA1c, basal/bolus distribution, meals/day, BMI, total daily dose (TDD), and carbohydrates/kg (CHO/kg) have been evaluated in 83 subjects, aged 13 ± 4.5 years, in manual mode, 3 and 6 months after auto-mode. Time in range (TIR) increased after 3 months, exceeding the target of 70% and was maintained at 6 months. While coefficient of variation (CV) did not change, the glucose management indicator (GMI) decreased in auto-mode (6.7 ± 0.3 vs. 7.1 ± 0.5%; p < 0.001), as well as HbA1c. Basal proportion decreased in favor of boluses (38.3 ± 7.3 vs. 43.6 ± 10.9%; p < 0.001). Meals increased at 3 and 6 months (4.4 ± 1.2 vs. 5.0 ± 1.5, p 0.002 and 5.1 ± 1.7, p < 0.001), as well as TDD/kg, without changes in BMI and CHO consumed. No differences in meal composition have arisen from food diaries. In conclusion, AHCL ensured the achievement and maintenance of target TIR in young T1D subjects. The number of meals, TDD, and insulin bolus proportion increased over time, but BMI remained stable.

Safety and Glycemic Outcomes During the MiniMedTM Advanced Hybrid Closed-Loop System Pivotal Trial in Children and Adolescents with Type 1 Diabetes

Background: During MiniMed™ advanced hybrid closed-loop (AHCL) use by adolescents and adults in the pivotal trial, glycated hemoglobin (A1C) was significantly reduced, time spent in range (TIR) was significantly increased, and there were no episodes of severe hypoglycemia or diabetic ketoacidosis (DKA). The present study investigated the same primary safety and effectiveness endpoints during AHCL use by a younger cohort with type 1 diabetes (T1D). Methods: An intention-to-treat population (N = 160, aged 7-17 years) with T1D was enrolled in a single-arm study at 13 investigational centers. There was a run-in period (∼25 days) using HCL or sensor-augmented pump with/without predictive low-glucose management, followed by a 3-month study period with AHCL activated at two glucose targets (GTs; 100 and 120 mg/dL) for ∼45 days each. The mean ± standard deviation values of A1C, TIR, mean sensor glucose (SG), coefficient of variation (CV) of SG, time at SG ranges, and insulin delivered between run-in and study were analyzed (Wilcoxon signed-rank test or t-test). Results: Compared with baseline, AHCL use was associated with reduced A1C from 7.9 ± 0.9% (N = 160) to 7.4 ± 0.7% (N = 136) (P < 0.001) and overall TIR increased from the run-in 59.4 ± 11.8% to 70.3 ± 6.5% by end of study (P < 0.001), without change in CV, time spent below range (TBR) <70 mg/dL, or TBR <54 mg/dL. Relative to longer active insulin time (AIT) settings (N = 52), an AIT of 2 h (N = 19) with the 100 mg/dL GT increased mean TIR to 73.4%, reduced TBR <70 mg/dL from 3.5% to 2.2%, and reduced time spent above range (TAR) >180 mg/dL from 28.7% to 24.4%. During AHCL use, there was no severe hypoglycemia or DKA. Conclusions: In children and adolescents with T1D, MiniMed AHCL system use was safe, A1C was lower, and TIR was increased. The lowest GT and shortest AIT were associated with the highest TIR and lowest TBR and TAR, all of which met consensus-recommended glycemic targets. ClinicalTrials.gov ID: NCT03959423.

Glycemic Outcomes During Early Use of the MiniMed™ 780G Advanced Hybrid Closed-Loop System with Guardian™ 4 Sensor

Background: Safety and significant improvement in overall glycated hemoglobin (A1C) and percentage of time spent in (TIR), below (TBR), and above (TAR) glucose range were demonstrated in the pivotal trial of adolescents and adults using the MiniMed™ advanced hybrid closed-loop (AHCL) system with the adjunctive, calibration-required Guardian™ Sensor 3. The present study evaluated early outcomes of continued access study (CAS) participants who transitioned from the pivotal trial investigational system to the approved MiniMed™ 780G system with the non-adjunctive, calibration-free Guardian™ 4 Sensor (MM780G+G4S). Study data were presented alongside those of real-world MM780G+G4S users from Europe, the Middle East, and Africa. Methods: The CAS participants (N = 109, aged 7-17 years and N = 67, aged >17 years) used the MM780G+G4S for 3 months and data of real-world MM780G+G4S system users (N = 10,204 aged ≤15 years and N = 26,099 aged >15 years) were uploaded from September 22, 2021 to December 02, 2022. At least 10 days of real-world continuous glucose monitoring (CGM) data were required for analyses. Glycemic metrics, delivered insulin and system use/interactions underwent descriptive analyses. Results: Time in AHCL and CGM use were >90% for all groups. AHCL exits averaged 0.1/day and there were few blood glucose measurements (BGMs) (0.8/day-1.0/day). Adults in both cohorts met most consensus recommendations for glycemic targets. Pediatric groups met recommendations for %TIR and %TBR, although not those for mean glucose variability and %TAR, possibly due to low use of recommended glucose target (100 mg/dL) and active insulin time (2 h) settings (28.4% in the CAS cohort and 9.4% in the real-world cohort). The CAS pediatric and adult A1C were 7.2% ± 0.7% and 6.8% ± 0.7%, respectively, and there were no serious adverse events. Conclusions: Early clinical use of the MM780G+G4S was safe and involved minimal BGMs and AHCL exits. Consistent with real-world pediatric and adult use, outcomes were associated with achievement of recommended glycemic targets. Clinical Trial Registration number: NCT03959423.

The changing landscape of automated insulin delivery in the management of type 1 diabetes

Automated insulin delivery systems, also known as closed-loop or 'artificial pancreas' systems, are transforming the management of type 1 diabetes. These systems consist of an algorithm which responds to real-time glucose sensor levels by automatically modulating insulin delivery through an insulin pump. We review the rapidly changing landscape of automated insulin-delivery systems over recent decades, from initial prototypes to the different hybrid closed-loop systems commercially available today. We discuss the growing body of clinical trials and real-world evidence demonstrating their glycaemic and psychosocial benefits. We also address future directions in automated insulin delivery such as dual-hormone systems and adjunct therapy as well as the challenges around ensuring equitable access to closed-loop technology.

Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023

Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.